14/10/2020 Brain death - Wikipedia

Brain death
Brain death is the complete loss of brain function (including involuntary activity necessary to
sustain life).[1][2][3][4] It differs from persistent vegetative state, in which the person is alive and some
autonomic functions remain.[5] It is also distinct from an ordinary coma, whether induced medically
or caused by injury and/or illness, even if it is very deep, as long as some brain and bodily activity and
function remain; and it is also not the same as the condition locked-in syndrome. A differential
diagnosis can medically distinguish these differing conditions.

Brain death is used as an indicator of legal death in many jurisdictions, but it is defined inconsistently
and often confused by the public.[6] Various parts of the brain may keep functioning when others do
not anymore, and the term "brain death" has been used to refer to various combinations. For
example, although one major medical dictionary[7] considers "brain death" to be synonymous with
"cerebral death" (death of the cerebrum), the US National Library of Medicine Medical Subject
Headings (MeSH) system defines brain death as including the brainstem. The distinctions are
medically significant because, for example, in someone with a dead cerebrum but a living brainstem,
spontaneous breathing may continue unaided, whereas in whole-brain death (which includes
brainstem death), only life support equipment would maintain ventilation. Patients classified as
brain-dead can have their organs surgically removed for organ donation.

Contents
Legal history
Medical criteria
Organ donation
See also
References
External links

Legal history
Traditionally, both the legal and medical communities determined death through the permanent end
of certain bodily functions in clinical death, especially respiration and heartbeat. With the increasing
ability of the medical community to resuscitate people with no respiration, heartbeat, or other
external signs of life, the need for another definition of death occurred, raising questions of legal
death. This gained greater urgency with the widespread use of life support equipment, as well as
rising capabilities and demand for organ transplantation.

Since the 1960s, laws on determining death have, therefore, been implemented in all countries with
active organ transplantation programs. The first European country to adopt brain death as a legal
definition (or indicator) of death was Finland in 1971. In the United States, Kansas had enacted a
similar law earlier.[8]

An ad hoc committee at Harvard Medical School published a pivotal 1968 report to define irreversible
coma.[9][10] The Harvard criteria gradually gained consensus toward what is now known as brain
death. In the wake of the 1976 Karen Ann Quinlan case, state legislatures in the United States moved
to accept brain death as an acceptable indication of death. In 1981 a Presidential commission issued a
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landmark report – Defining Death: Medical, Legal, and Ethical Issues in the Determination of Death
[11] – that rejected the "higher brain" approach to death in favor of a "whole brain" definition. This
report was the basis for the Uniform Determination of Death Act, which has been enacted in 39 states
of the United States.[12] The Uniform Determination of Death Act in the United States attempts to
standardize criteria. Today, both the legal and medical communities in the US use "brain death" as a
legal definition of death, allowing a person to be declared legally dead even if life support equipment
keeps the body's metabolic processes working.[13]

In the UK, the Royal College of Physicians reported in 1995, abandoning the 1979 claim that the tests
published in 1976 sufficed for the diagnosis of brain death and suggesting a new definition of death
based on the irreversible loss of brain stem function alone.[14] This new definition, the irreversible
loss of the capacity for consciousness and for spontaneous breathing, and the essentially unchanged
1976 tests held to establish that state, have been adopted as a basis of death certification for organ
transplant purposes in subsequent Codes of Practice.[15][16] The Australia and New Zealand Intensive
Care Society (ANZICS) states that the "determination of brain death requires that there is
unresponsive coma, the absence of brain-stem reflexes and the absence of respiratory centre function,
in the clinical setting in which these findings are irreversible. In particular, there must be definite
clinical or neuro-imaging evidence of acute brain pathology (e.g. traumatic brain injury, intracranial
haemorrhage, hypoxic encephalopathy) consistent with the irreversible loss of neurological
function."[17]

Medical criteria
Natural movements also known as the Lazarus sign or Lazarus reflex can occur on a brain-dead
person whose organs have been kept functioning by life support. The living cells that can cause these
movements are not living cells from the brain or brain stem; these cells come from the spinal cord.
Sometimes these body movements can cause false hope for family members.

A brain-dead individual has no clinical evidence of brain function upon physical examination. This
includes no response to pain and no cranial nerve reflexes. Reflexes include pupillary response (fixed
pupils), oculocephalic reflex, corneal reflex, no response to the caloric reflex test, and no spontaneous
respirations.

Brain death can sometimes be difficult to differentiate from other medical states such as barbiturate
overdose, alcohol intoxication, sedative overdose, hypothermia, hypoglycemia, coma, and chronic
vegetative states. Some comatose patients can recover to pre-coma or near pre-coma level of
functioning, and some patients with severe irreversible neurological dysfunction will nonetheless
retain some lower brain functions, such as spontaneous respiration, despite the losses of both cortex
and brain stem functionality. Such is the case with anencephaly.

Brain electrical activity can stop completely, or drop to such a low level as to be undetectable with
most equipment. An EEG will therefore be flat, though this is sometimes also observed during deep
anesthesia or cardiac arrest.[18] Although in the United States a flat EEG test is not required to certify
death, it is considered to have confirmatory value. In the UK it is not considered to be of value
because any continuing activity it might reveal in parts of the brain above the brain stem is held to be
irrelevant to the diagnosis of death on the Code of Practice criteria.[19]

The diagnosis of brain death is often required to be highly rigorous, in order to be certain that the
condition is irreversible. Legal criteria vary, but in general require neurological examinations by two
independent physicians. The exams must show complete and irreversible absence of brain function
(brain stem function in UK),[20] and may include two isoelectric (flat-line) EEGs 24 hours apart (less
in other countries where it is accepted that if the cause of the dysfunction is a clear physical trauma

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there is no need to wait that long to establish irreversibility). The patient should have a normal
temperature and be free of drugs that can suppress brain activity if the diagnosis is to be made on
EEG criteria.

Also, a radionuclide cerebral blood flow scan that shows complete

absence of intracranial blood flow must be considered with other
exams – temporary swelling of the brain, particularly within the
first 72 hours, can lead to a false positive test on a patient that
may recover with more time.[21]

CT angiography is neither required nor sufficient test to make the

diagnosis.[22]

Confirmatory testing is only needed under the age of 1.[2] For

children and adults, testing is optional. Other situations possibly
requiring confirmatory testing include severe facial trauma where
determination of brainstem reflexes will be difficult, pre-existing Radionuclide scan: No intracranial
pupillary abnormalities, and patients with severe sleep apnea blood flow. The "hot-nose" sign is
and/or pulmonary disease.[2] Confirmatory tests include: cerebral shown.
angiography, electroencephalography, transcranial Doppler
ultrasonography, and cerebral scintigraphy (technetium Tc 99m
exametazime). Cerebral angiography is considered the most sensitive confirmatory test in the
determination of brain death.[2]

Organ donation
While the diagnosis of brain death has become accepted as a basis for the certification of death for
legal purposes, it is a very different state from biological death - the state universally recognized and
understood as death.[23] The continuing function of vital organs in the bodies of those diagnosed
brain dead, if mechanical ventilation and other life-support measures are continued, provides optimal
opportunities for their transplantation.

When mechanical ventilation is used to support the body of a brain dead organ donor pending a
transplant into an organ recipient, the donor's date of death is listed as the date that brain death was
diagnosed.[24]

In some countries (for instance, Spain,[25] Finland, Wales, Portugal, and France), everyone is
automatically an organ donor after diagnosis of death on legally accepted criteria, although some
jurisdictions (such as Singapore, Spain, Wales, France, Czech Republic, Poland and Portugal) allow
opting out of the system. Elsewhere, consent from family members or next-of-kin may be required for
organ donation. In New Zealand, Australia, the United Kingdom (excluding Wales) and most states in
the United States, drivers are asked upon application if they wish to be registered as an organ
donor.[26]

In the United States, if the patient is at or near death, the hospital must notify a transplant
organization of the person's details and maintain the patient while the patient is being evaluated for
suitability as a donor.[27] The patient is kept on ventilator support until the organs have been
surgically removed. If the patient has indicated in an advance health care directive that they do not
wish to receive mechanical ventilation or has specified a do not resuscitate order and the patient has
also indicated that they wish to donate their organs, some vital organs such as the heart and lungs
may not be able to be recovered.[28]

See also
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Brainstem death
Clinical death
Death
Persistent vegetative state
Information-theoretic death
Consciousness after death
Klaus Schäfer, Understand brain death PDF in German (https://epub.uni-regensburg.de/36456/1/v
erstehen.pdf)

References
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6. Jones AH, Dizon ZB, October TW (August 2018). "Investigation of Public Perception of Brain
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8. (Randell T. (2004). "Medical and legal considerations of brain death". Acta Anaesthesiologica
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Fj.0001-5172.2004.00304.x). PMID 14995934 (https://pubmed.ncbi.nlm.nih.gov/14995934).
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to Examine the Definition of Brain Death". JAMA. 205 (6): 337–40. 1968.
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g=PA59). DIANE Publishing. 1987. ISBN 9781428922815 – via Google Books.
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17/http://uniformlaws.org/LegislativeFactSheet.aspx?title=Determination). Uniform Law
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etermination%20of%20Death%20Act) on 3 September 2018. Retrieved 8 May 2012.

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13. "Uniform Determination of Death Act" (https://web.archive.org/web/20160304131421/http://pntb.or

g/wordpress/wp-content/uploads/Uniform-Determination-of-Death-1980_5c.pdf) (PDF). National
Conference of Commissioners on Uniform State Laws. Archived from the original (http://pntb.org/
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2016. Retrieved 26 March 2014.
14. "Criteria for the diagnosis of brain stem death. Review by a working group convened by the Royal
College of Physicians and endorsed by the Conference of Medical Royal Colleges and their
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Coll Physicians Lond. 29 (5): 381–2. 1995. PMC 5401215 (https://www.ncbi.nlm.nih.gov/pmc/articl
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Colleges. 70 Wimpole Street, London, 2008
16. American Academy of Neurology. (2000, January 13).Spontaneous Movements Often Occur After
Brain Death.Science Daily.
17. "The ANZICS Statement on Death and Organ Donation" (https://web.archive.org/web/201803192
02056/http://www.anzics.com.au/Downloads/ANZICS%20Statement%20on%20%20Death%20an
d%20Organ%20Donation%20Edition%203.2.pdf) (PDF) (3.2 ed.). Melbourne: Australian and New
Zealand Intensive Care Society. 2013: 17. ISBN 1876980214. Archived from the original (http://w
ww.anzics.com.au/Downloads/ANZICS%20Statement%20on%20%20Death%20and%20Organ%
20Donation%20Edition%203.2.pdf) (PDF) on March 19, 2018.
18. Karasawa, H; et al. (Jan 2001). "Intracranial electroencephalographic changes in deep
anesthesia". Clin Neurophysiol. 112 (1): 25–30. doi:10.1016/s1388-2457(00)00510-1 (https://doi.o
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Street, London, 2008
20. Waters, C. E.; French, G.; Burt, M. (2004). "Difficulty in brainstem death testing in the presence of
high spinal cord injury" (http://bja.oxfordjournals.org/content/92/5/760.full). British Journal of
Anaesthesia. 92 (5): 760–4. doi:10.1093/bja/aeh117 (https://doi.org/10.1093%2Fbja%2Faeh117).
PMID 15113764 (https://pubmed.ncbi.nlm.nih.gov/15113764).
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theness.com. 2008-04-08.
22. Taylor, T; Dineen, RA; Gardiner, DC; Buss, CH; Howatson, A; Pace, NL (Mar 31, 2014).
"Computed tomography (CT) angiography for confirmation of the clinical diagnosis of brain death"
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6517290). The Cochrane Database of Systematic
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4651858.CD009694.pub2). PMC 6517290 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC65172
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23. Truog RD, Miller FG. The meaning of brain death. JAMA Internal Medicine 2014, Publ online June
9, 2014 : http://archinte.jamanetwork.com
24. "Understanding Brain Death" (http://www.donorrecovery.org/learn/understanding-brain-death/).
"What is the legal time of death for a brain dead patient? The legal time of death is the date and
time that doctors determine that all brain activity has ceased. This is the time that is noted on the
patient’s death certificate."
25. Organización Nacional de Transplantes – Consentimiento familiar y donación (http://www.ont.es/i
nformacion/Páginas/Donaci%C3%B3n.aspx)
26. "National Donate Life America Donor Designation State Report Card 2013" (https://web.archive.or
g/web/20140322222952/http://donatelife.net/wp-content/uploads/2013/07/DLA_ReportCardFinal_
2013.pdf) (PDF). pp. 6 & 7. Archived from the original (http://donatelife.net/wp-content/uploads/20
13/07/DLA_ReportCardFinal_2013.pdf) (PDF) on 2014-03-22. "2012 State Comparisons"

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27. "State and Federal Law on Organ Procurement" (https://web.archive.org/web/20140306072928/ht

tp://www.wsha.org/EOL-OrganProcurement.cfm). Archived from the original (http://www.wsha.org/
EOL-OrganProcurement.cfm) on 2014-03-06. "Unless the individual expressed contrary intent, a
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"DNR will be honored. You can still be a tissue donor."

External links
Classification ICD-10-CM: D
G93.82 (https://icdc
odelookup.com/icd-
10/codes/G93.82) ·
ICD-9-CM: 348.82
(http://www.icd9dat
a.com/getICD9Cod
e.ashx?icd9=348.8
2) · MeSH:
D001926 (https://w
ww.nlm.nih.gov/cgi/
mesh/2015/MB_cg
i?field=uid&term=D
001926) ·
DiseasesDB: 1572
(http://www.disease
sdatabase.com/ddb
1572.htm)

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